Shoulder Pain as an Unusual Presentation of Pneumonia in a Stroke Patient: A Case Report

Wannapha Petchkrua, MD, Stacy A. Harris, MD(Arch Phys Med Rehabil 2000;81:827-9)

Deta Tanuwidjaja, dr.Department of Physical Medicine & RehabilitationFaculty of Medicine Universitas Padjadjaran

Supervised by: Irma Hassan Hikmat, dr., SpRad(K).

7th Journal ReadingJuly 10th, 2013

INTRODUCTION

Shoulder Pain in hemiplegia

most frequent complication

Impairment Disability Handicap

• 38-70 % incidence of HSPGriffin

• 41 % HSP 3years post stroke 48% unspecifiedPoduri

INTRODUCTION

Totta & Beneck

Glenohumeral subluxation

Frozen shoulderImpingement

syndromeRotator cuff lesions

Brachial plexus neuropathy

Reflex sympathetic dystrophy

Other Causes

FracturesPreexisting arthritis

TumorCervical disc disease

Heterotopic ossification Radicular and referred pain

INTRODUCTION

Gresham:Most of stroke patient

are elderly

• Referred pain of cardiac origin ??

Griffin

•Medical history•Thorough diagnostic examination

If Negative: Consider less

common causes

CASE REPORT

•Osteoporosis (+)•Localized colon cancer & Elective cholecystectomy•Brain CT Scan: bilateral calcification in the basal ganglia•ECG: normal left ventricular function•MRI: ischemic leukoencephalopathy with scattered lacunar infarctions on the left side left internal capsule white matter

89-year-old woman

Chief Complaint:

sudden right-sided

weakness & slurred speech

CASE REPORT

Day 3 Day 5

Admission

Transferred to Rehabilitation

Unit

Spasticity Ashworth I

Sudden onset of severe right shoulder pain & mild right-sided rib pain

Shortness of breath, pleuritic pain, cough, gastrointestinal symptoms denied

Vital sign normal, Sat O2 97%Edema, tenderness, skin change (-)

Cervical ROM normal, Subluxation (-), Right glenohumeral ROM decreased with tenderness

Supporting Examination on Day 5

• questionable acromioclavicular joint separation shoulder sling discontinued (after consult to orthopedics)

Right Shoulder X-Ray

• No DVTVenous Doppler

• Negative for acute changeECG• Read negative by Radiologist reviewed right

heart border haziness start clarythromycinChest X-Ray• High ESR & RF• ANA, protein C, C3 complement & serum protein

electrophoresis normalBlood Test

CASE REPORT

Day 6 Day 7

Greenish sputum, Temp 380C, WBC 11.600

(85,9% neutrophyl) Susp Pneumonia

Medical oral expectorant, antibiotics

Chest Physiotherapy hydration, postural

percussion & drainage, incentive spyrometry

Chest X-ray: infiltrationand atelectasis medial

aspect of the right lowerlobe

Pain Resolved

Glenohumeral ROM back to

normal

Day 12

Chest X-ray on Day 7

DISCUSSION

Zuckerman & Shapiro, Totta & Beneck , Poduri

The Unlikely Diagnosis

• high ESR and rheumatoid factor, but ANA, protein C, C3 complement, and serum protein electrophoresis were negative

Inflamatory Arthritis

• Normal X-RayFracture, HO,

Calcific Tendinitis

•Spasticity, Exercise, Handling unlikely by history & physical exam•X-Ray shows no cancer•Serum electrophoresis did not suggest multiple myeloma

Extrinsic Disorder

The Unlikely Diagnosis

• Risk factor (+)• Pain location atypical (sharp &

reproducible with palpation

Cardiac Ischemia

• The patient received low dose heparin

• Doppler (-)• Anand et al algorithm moderate

risk with normal venous doppler

DVT

Less Common but Likely Diagnosis

•Occur in 30% Stroke patient•Harper & Newton absence of classic sign correlated with age (>65) & cognitive & baseline functional impairment on admission

PNEUMONIA

Referred pain from pulmonary organ

Shoulder Pain & decreased ROM resolved after pulmonary toilet & antibiotic

PROBABLE SOURCE OF PAIN

CONCLUSION

A high index of suspicion and early treatment may prevent morbidity

THANK YOU